2024 MLK Camp

Player Name: *

Age: ______ DOB _______ *

Address *

City *

Zip Code *

Cell Phone Number *

Emergency Contact Number *

Email Address *

League *

Camp Sessions *

Sun. & Mon. January 14th, 15th

Cost $170.00 Type of Payment *

Card Number ( If paying by Check, Cash or Gift Certificate type N/A *

CCV Number *

Expiration Date: __ __/ __ __/ __ __ __ __ *

Credit Card Billing Zip Code *

Customer Name ( Print ) *

Release of Liability Agreement and Insurance Information *

I, __________________________
[Print name of parent or guardian]

HEREBY ACKNOWLEDGE that I have voluntarily permitted ___________________________ [Print name of PARTICIPANT]
to participate in the game of baseball, baseball camp and/or other activities under the direction of Robert A. Nelson, II and Kathleen T. Nelson, individually and d.b.a. Hit One Deep Enterprises and on the premises and facilities of Temple City High School and Temple City Unified School District (collectively hereinafter NELSON/TEMPLE”)
I AM AWARE THAT BASEBALL (OR ANY OTHER PROGRAM OFFERED UNDER THE DIRECTION OF and ON THE PREMISES AND FACILITIES OF “NELSON/TEMPLE”) ARE HAZARDOUS, AND I AM VOLUNTARILY PERMITTING PARTICIPANT TO PARTICIPATE IN THESE ACTIVITIES WITH KNOWLEDGE OF THE DANGER INVOLVED AND HEREBY AGREE TO ACCEPT ANY AND ALL RISKS OF INJURY OR DEATH TO PARTICIPANT THAT MAY RESULT THEREFROM.
In exchange for Participant being permitted by “NELSON/TEMPLE” to participate in these activities and/or use their facilities, I HEREBY AGREE THAT I WILL NOT MAKE A CLAIM AGAINST OR SUE “NELSON/TEMPLE” or any of their principals, employees or agents, for injury and damage resulting from the negligence or other acts, howsoever caused, by any employee or agent of “NELSON/TEMPLE” as a result of Participant’s participation in any activity under the direction of and on the premises of “NELSON/TEMPLE”.
In addition, I HEREBY ACKNOWLEDGE AND AGREE TO RELEASE, DEFEND, INDEMNIFY AND HOLD HARMLESS “NELSON/TEMPLE”, their principals, employees and agents, and to ASSUME FULL RESPONSIBILITY FOR ANY LOSS OR DAMAGE OR ANY CLAIM, LAWSUIT OR DEMAND FOR LOSS OR DAMAGE, on account of injury to PARTICIPANT, whether caused by the active, passive or sole negligence of “NELSON/TEMPLE,” their employees or agents, while PARTICIPANT is participating in any way in any activity under the direction of and on the property and facilities of “NELSON/TEMPLE.” 
Should it be necessary, in the opinion of Robert A. Nelson, II, to render first aid and assistance to Participant, I hereby grant permission to Robert A. Nelson, II to render such aid and assistance.
I HAVE CAREFULLY READ THIS AGREEMENT AND RELEASE OF LIABILITY AND FULLY UNDERSTAND ITS CONTENTS AND SIGN IT OF MY OWN FREE WILL.

Signed:__________________________________

Dated:______________________________

Name of Insurance Company: _______________________________

Policy Number: ___________________________________

Report abuse